Screening For Child Abuse In Children With Isolated Skull Fractures
Stephanie Y Chen1, Leland Gao2, Karen K Imagawa1, Eric R Roseman1, Cathy E Shin1, Eugene S Kim1, Ryan Spurrier1
1Children's Hospital Los Angeles, Los Angeles, CA;2Keck School of Medicine of the University of Southern California, Los Angeles, CA
Background: Head trauma is the most common cause of death in child abuse, and each encounter for recurrent physical abuse is associated with greater morbidity. Children with isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We aimed to determine patterns of physical abuse screening in our ED for children with ISF. Methods: An IRB-approved retrospective chart review was performed for children ≤ 3 years who presented to our ED from 01/01/2015-12/31/2019 with head trauma and ISF diagnosis. Primary outcome was social work (SW) assessment to prescreen for possible abusive environment. Secondary outcomes included suspicion for physical abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. Results: 66 patients with ISF were identified (41F:25M). Unwitnessed injuries were reported in 33.3% (n=22) and witnessed injuries reported in 66.7% (n=44). Of unwitnessed injury patients, 77.3% (17/22) were <12 months. Of these, 88.2% (15/17) underwent SW assessment and 47.1% (8/17) were referred to CPS. Of witnessed injury patients, 52.3% (23/44) were <12 months. Of these, 60.9% (14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (4/22) unwitnessed injury patients and 20.5% (9/44) witnessed injury patients returned to our ED within 1 year. One patient from each group returned for recurrent trauma, and both were <12 months. Conclusions: We maintain a high level of vigilance in screening for physical abuse, particularly in children age <12 months. To decrease risk of missed physical abuse, future considerations include consulting SW for all patients with ISF, regardless of whether injury was witnessed or unwitnessed.
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